Nursing Elites

1. The client had surgery one day ago. What assessment is most likely related to pain?

• A. Blood pressure of 175/90 mm Hg
• B. Respirations of 10 breaths per minute
• C. Heart rate 60 beats/minute
• D. Oxygen saturation of 97%

Correct answer: A

Rationale:

2. What is not appropriate client education on the preventing the spread of methicillin- resistance Staphylococcus aureus (MRSA)?

• A. Avoid contact sports until the infection has cleared
• B. Use a bath sponge to cleanse the skin
• C. Wash hands with soap and water before and after touching the infected area
• D. Use an antibacterial soap when showering

Correct answer: B

Rationale:

3. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?

• A. Observe client for changes in mental status
• B. Use aseptic technique for wound care and emptying of drains
• C. Keep the client's heels off the bed
• D. Perform neurovascular assessments per protocol

Correct answer: D

Rationale:

4. The client states, “the doctor says I am nearsighted. I do not get it.” What would be the best response by the nurse?

• A. I am sorry you did not understand. Would you like a different doctor?
• B. Nearsighted, or myopia means that you have difficulty seeing things at a distance.
• C. You will need to have glasses.
• D. This means you won’t ever need glasses.

Correct answer: B

Rationale: The correct response is to explain to the client what nearsightedness means, which is having difficulty seeing distant objects, as known as myopia. Choice A is not helpful as changing doctors is not necessary for this situation. Choice C is premature as wearing glasses is a possible solution but not the only one. Choice D is incorrect as nearsightedness (myopia) often requires glasses for correction.

5. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?

• A. Send the client back to surgery
• B. Assess the wound for signs of dehiscence
• C. Call the provider immediately
• D. Prepare to culture the wound

Correct answer: B

Rationale:

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